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Annex

WEP
for an additional person aged 15 years or older in the demand
group
(on Section 2.1 of the main
- For children under 15 years of age, please fill in the attachment KI -
proposal)
2
Applicable Find more information
Processing notes
plea to the respective number To be filled in only by the Jobcenter
se
tick in the completion notes
You will find the filling instructions and other enclosures on the Internetwww.arbeitsagentur.d
at .
1. my personal data e

Salutat First Stamp of receipt

ion name

Family name Date of birth

Number of the demand group (if available) Customer (if available)

number

2. another person in my community of needs over the age of 15 who Office

refer to the information in this 9

2.1 Annex
Personal data
Team
Salutat First
ion name
Customer number of the additional
Family name Name at birth (if different) person

Place of Date of birth AZR number of the additional

birth person

Country of Nationality Personal identification number of

birth the other(for Romanian and
Person
Bulgarian-
nationals)
Pension insurance number 1 Pension insurance number was
applied
for
2.2 Marital status

The other person is

singl married widowed
e
divorced since permanently separated
living since

The same-sex civil partnership of the further person is

registered since suspended

since

2.3 Personal data

I am related to the other person.

My partner is related to the other person.

Relationship

The additional person has or for the additional person was Y No

appointed
the month forin which the application is made, benefits are es
already paid
applied for ortoobtained
a from another job centre.
► If so, please provide appropriate evidence.

Job Center Page 1 of 4

WEP.04.2019
 The other person is a Spätaussiedler and Y No Processing notes
does not yet have German citizenship. 4 es To be filled in only by the Jobcenter
► If so, please submit the notification of admission. notification of
admission
The other person is entitled to the asylum according to the asylum Y No
application-
the law on benefits. 5 es
► Please submit appropriate proof (e.g. residence permit, residence permit, toleration, notification
of the Federal Office for Migration and Refugees (BAMF))
The other person is - according to their assessment - in good health in Y No
Ability to carry out an activity of at least three hours a day. 6 es
► If you ticked No, the additional person may not be entitled to benefits
according to the Second Book of the Social Security Code. In this case, it may grant benefits under the Twelfth Book
Social Security Code (SGB XII).

The other person is a pupil. 7 Y No

es
Duration of school education from - ► If so, please put in the appropriate...
to the supporting documents (e.g. school
certificates-
gung).

The other person is a student. 7 Y No

es
Duration of studies from - to ► If so, please put in the appropriate...
de proofs (e.g. matriculation
certificate).
The other person has benefits according to the Y No
Bundesausbildungsförde-
tion Act (BAföG) was applied es
for.If yes, please submit proof of the application or - if already submitted via BAföG application
►
has been decided - submits the corresponding decision on approval or rejection.

The other person is a trainee/apprentice. 7 Y No

es
Duration of training from - to ► If so, please put the training
contract.
Training contract
During the training the further person is in a dormitory, boarding school or at the
Trainers with full board or otherwise with reimbursement of expenses for
accommodation
and catering.
► If so, please provide appropriate evidence.

The other person is currently or will soon be in a Y No

in-patient facility (e.g. hospital, retirement home, judicial es
correctional 8
facility).
Duration of accommodation from - Type of stationary device
to

► If yes, please provide a valid certificate of residence and duration.

3. examination of additional
needs
The information is voluntary and is only required if you wish to apply for additional requirements.

The other person is pregnant. 14

► Please provide proof of the expected date of delivery.
The additional person requires a costly diet for medical reasons.
tion. 15
► Please fill in the Plant MEB out. Plant MEB
The other person has a disability and receives 16

- Benefits for participation in working life according to § 49 Book of Ninths of the

SocialIX)
(SGB Code
or
•- other assistance in obtaining a suitable job, or
-• Integration assistance according to § 54, Subsection 1,
Sentence 1, Nos. 1-3, SGB XII.
► • Please submit a corresponding notification.
The other person is not fit for work and
6 holder of an identity card
according to § 152, Subsection 5, SGB IX with the mark G 17
or Please
► aG. submit appropriate proof.

Job Center *S2 Page 2 of 4

WEP.04.2019
 Processing notes
The other person has an undeniable, ongoing, not only one-time, but also regular
To be filled in only by the Jobcenter
special needs which they do not meet through savings or other means.
(e.g. costs of exercising rights of access in the event of separation)
parent 18
s). Please fill in the Annex BB out.
► Annex BB
4. income 19

The other person earns income and/or is self-employed Y No

activity (including agriculture and forestry). es
► If yes, please fill in the Annex EK out. When exercising a self-employed activity Annex EK
please additionally fill in the Plant EKS out. Plant EKS
5. assets 20

The other person has assets. Y No

es
► Please provide information on the financial circumstances of all persons in the consumer association
into Annex VM on. Annex VM
the
6. priority claims 21

6.1 Claims against the Federal Employment 22

Agency
► If the other person already applies for unemployment benefit according to the Third Book of the Social Code (SGB III)
please enter this in section 6.4. If the unemployment benefit has already been approved, the
you can seeAnnex EK Section 2 on. This also applies if a blocking period has occurred. In either case...
If you
this in do not make any entries in section 6.1.
Within the last 5 years before the application
► The following information is used to check whether you could be entitled to unemployment benefit.
► Multiple answers are possible here. If necessary, use a separate sheet of paper and place the appropriate
sive evidence.
the other person was employed subject to social insurance
contributions.
from - to Employer type of work

from - to Employer type of work

the other person was self-employed.

from - to type of work

the additional person has performed military or

alternative service.
the other person has cared for relatives (care according to the Eleventh Book of Social
book).
Law -
the other person has received compensation benefits (e.g. sickness benefit,
tion in accordance
unemployment with etc.)
benefit,
SGB
from III).
- to Authorit Perform
y ance

6.2 Claims against employers

The additional person makes claims against a (former) employer for still
Outstanding wage or salary payments (e.g. in the event of insolvency/insolvency of
employer) or for periods after leaving the company (e.g. if the severance pay is still
outstanding)
dungen).
► Please provide appropriate supporting documents.

6.3 Claims against third parties

The other person has suffered damage to his or her health (e.g. due to an ar-
occupational, traffic, play or sports accident, a medical malpractice or by
a physical confrontation). She has therefore become in need of help.
► Please fill in the Plant UF out. Plant UF

Job Center
WEP.04.2019
*S3 Page 3 of 4
 The additional person has a claim against third parties (e.g. from contractual payment Processing notes
obligations).
claims or claims for damages). 23 To be filled in only by the Jobcenter
Description of the claim

► Please provide evidence of the claim by means of appropriate documents.

6.4 Claims against social benefit agencies/family funds 24

The other person already has other benefits (e.g. housing benefit, unemployment
pension, child benefit) or intends to make an application.
benefit,
Service Social benefit agency/family fund
type

Date of Services requested

application from

► Please provide evidence if a decision has already been taken on the application(s).

7. health and nursing care 25

insurance
7.1 Compulsory insurance in the statutory health and nursing care
insurance
The other person is or was last in the statutory health and nursing care insurance
insurance, either compulsory or family
scheme
insurance.
Name of health Seat of the health Health insurance number
insurance company insurance company (if known)

► Please submit a certificate of membership or other proof of health insurance about

insurance of the further person. Alternatively, you can also use the valid electronic health insurance
card to the next person.

The other person is insured with the family and will be compulsorily 26
insured with
of the previous health
insurance company.
of another health insurance
company.
Name of health Seat of the health
insurance company insurance company

► Please submit a certificate of membership or other proof of health insurance about

the choice of health insurance company if the other person changes health insurance companies.
7.2 Private, voluntarily statutory or missing health and nursing care insurance
The other person is private or free
The additional person is not insured.
willingly insured by law.
► Please fill in the Annex SV, Section 2 out. ► Please fill in the Annex SV, Section 3 out. Annex SV
The data are subject to social secrecy (see "Merkblatt SGB II"). Your information will be treated according to §§ 60-65
First Book of the Social Code (SGB I) and §§ 67a, b, c Tenth Book of the Social Code (SGB X) for the Leis-
in accordance with SGB II. You can obtain data protection information from the Job-
center and on the Internet at www.arbeitsagentur.de/datenerhebun .
I confirm that the information provided g is
correct.
Place/Dat Signature Applicant
e (for minors: Signature of the legal representative)

► To be completed only in the event of amendments and additions:

I confirm the correctness of the information provided by me or the employees of the Job-
centers made changes and additions to the sections:

Place/Dat Signature Applicant

e (for minors: Signature of the legal representative)

Print form Reset form

Job Center
WEP.04.2019
*S4 Page 4 of 4